BJU International (2000), 86, 523±526

POINT OF TECHNIQUE
The buried penis ± an anatomical approach
N . S M E U L D E R S , D . T . W I L C O X * ² and P . M . C U C K O W ² ³
Institute of Child Health, *Great Ormond Street Hospital for Children and ²Guy's Hospital, and *³The Institute of Urology &
St. Peter's, The Middlesex Hospital, London, UK

surgery between August 1998 and February 1999. At 6

months follow-up, penile protrusion was good and the
Indications
cosmetic appearance very satisfactory. So far, none of the
Surgical correction of the buried penis is a dif®cult patients have shown signs of recurrent burying of the
challenge. Many different procedures have been penis.
described but the results have generally been disappoint-
ing. Re-evaluation of the anatomy of this condition
Comparison with other methods
suggests that it results from a failure of separation of the
migrational planes in the developing male external Published opinions vary greatly as to the underlying
genitalia. During the sixth week of development, the cause of the buried penis. Many authors describe
scrotal swellings start to appear on either side of the adhesions tethering the penile shaft deeply, which most
urethral folds. At the cranial tip of the urethral folds is the thought originated from dartos fascia [2±7]. We think
genital tubercle; this rapidly elongates into the phallus,
pulling the urethral folds forward. The urethral folds fuse
over the urethral plate to form the penile urethra.
Meanwhile, the scrotal swellings, which are initially
found in the inguinal region, migrate caudally, where
they unite across the scrotal septum [1].
If these developmental planes fail to separate, the
penile corpora are tethered to the deep fascia, while the
scrotum remains high up in the groin. Herein we describe
a new technique to correct the buried penis, based on
these anatomical principles, whereby the penis gains the
normal circumcised appearance.

Methods
An incision is made between the scrotal and penile shaft
skin (Fig. 1). Dissection to the deep fascia allows the
scrotum to assume a more caudal position (Fig. 2). On
either side of the penile shaft, an alveolar tissue plane is
apparent between the penile Buck's fascia and Scarpa's
fascia. Circumferential dissection along Buck's fascia
frees the penis from its deep tetherings. Continuing the
dissection distally lifts the preputial sac off the penile shaft
(Fig. 3). The preputial sac is opened on its ventral surface
and the redundant inner preputial skin excised, leaving a
cuff of mucosa under the glans (Fig. 4). The rectangle of
penile skin is wrapped around the shaft and anastomosed
to the mucosal cuff. The remaining diamond-shaped
ventral incision is closed in a vertical line. The
appearance is that of the circumcised penis (Fig. 5).
Six boys, aged from 11 months to 4 years, underwent Fig. 1. An incision is made between the scrotal and penile shaft skin.

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524 POINT OF TECHNIQUE

Fig. 2. Dissection to the deep fascia allows the scrotum to assume a Fig. 3. Circumferential dissection along Buck's fascia frees the penis
more caudal position. On either side of the penile shaft, an alveolar from its deep tetherings. Continuing the dissection distally lifts the
tissue plane is seen between the penile Buck's fascia and Scarpa's preputial sac off the penile shaft.
fascia.

[4,6,7,14], division of the suspensory ligament of the

that the failure of the migrational tissue planes to penis [5,10], preputial unfurling [7,9,11,12], anchoring
separate in the developing male external genitalia causes of the skin to the base of the penis [4±7,11±13,14,15] or
a persistence of adhesions between these planes. This even to the symphysis pubis [10], open lipectomy
understanding is essential for the adequate release of the [4,5,10,13,14], various `Z'-plasties [4,5,9,13,15] and
buried penis, as both the penile shaft and the scrotum are skin ¯aps [2,3]. Both ventral [6,7,15,16] and dorsal
affected. Interestingly, Kenawi [8] postulated a similar [2,5,11,14,15] approaches are described.
cause for the appearance of the webbed penis. In his view, The present technique most resembles that by Joseph
a partial failure of the posterior migration of the [6]. After a transverse ventral incision at the penoscrotal
labioscrotal folds might explain this condition. junction, Joseph carried out an extensive dissection at the
Other theories for the underlying defect in the buried base of the penis and along the penile shaft. This is similar
penis have been a paucity of penile shaft skin [3,7,9], to the present method, although it does not require as
inadequate attachment of skin and dartos fascia to the extensive a dissection at the root of the penis, because a
penile Buck's fascia [10±13], excessive suprapubic low fusion of the corpora is probably not responsible for
adipose tissue [4,5,11] and an abnormally low union the buried penis; nor are anchoring sutures placed. As in
of the crura to form the penile root [6]. As a consequence the present method, Joseph excised the inner preputial
of these hypotheses, many different procedures for the skin, without compromising skin cover.
correction of the buried penis have been described. These The present technique can be further compared with
include the release of penile shaft adhesions that of Boemers and De Jong [7], which uses a ventral
[2±4,6,7,9,11], degloving of the penis to Buck's fascia dissection down to the base of the penis and upper
[3,4,9,12,14,15], dissection of the root of the penis scrotum. In contrast, the scrotal dissection in the present

# 2000 BJU International 86, 523±526

 P O I N T OF TE C H N IQ U E 525

Fig. 4. Excision of the redundant inner preputial skin leaves a cuff of Fig. 5. The remaining, diamond-shaped ventral incision is closed in
mucosa under the glans and a rectangle of penile skin, which are a vertical line, leaving the circumcised appearance.
then anastomosed.
3 Wollin M, Duffy PG, Malone PS, Ransley PG. Buried penis. A
method extends much further laterally and no sutures novel approach. Br J Urol 1990; 65: 97±100
®xing the dartos fascia to the base of the penis are 4 Bergeson PS, Hopkin RJ, Bailey RB Jr, McGillLC, Piatt JP.
required. While those authors used unfurled preputial The inconspicuous penis. Pediatrics 1993; 92: 794±9
5 Alter GJ, Horton CE, Horton CE Jr. Buried penis as a
skin to achieve skin cover, we found that release of the
contraindication for circumcision. J Am Coll Surg 1994;
above adhesions results in a good length of penile skin for
178: 487±90
closure, allowing excision of the abnormal inner 6 Joseph VT. A new approach to the surgical correction of
preputial skin. buried penis. J Pediatr Surg 1995; 30: 727±9
7 Boemers TML, De Jong TPVM. The surgical correction of
buried penis: a new technique. J Urol 1995; 154: 550±2
Advantages
8 Kenawi MM. Webbed penis. Br J Urol 1973; 45: 569
The advantages of the present technique are that by 9 Donahoe PK, Keating MA. Preputial unfurling to correct the
dissecting the tissue planes, the penile shaft is freed of the buried penis. J Pediatr Surg 1986; 21: 1055±7
deep attachments and the scrotum assumes a more 10 Maizels M, Zaontz M, Donovan J, Bushnick PN, Firlit CF.
caudal position. Re-covering the penis with dorsal skin Surgical correction of the buried penis: description of a
classi®cation system and a technique to correct the disorder.
allows for a normal circumcised appearance.
J Urol 1986; 136: 268±71
11 Lipszyc E, P®ster C, Liard A, Mitrofanoff P. Surgical
treatment of buried penis. Eur J Pediatr Surg 1997; 7:
References 292±5
1 Sadler TW. Langman's Medical Embryology. 6th edn. Chapt 12 Cromie WJ, Ritchey ML, Smith RC, Zagaja GP. Anatomical
15. New York: William and Wilkins, 1990: 283±6 alignment for the correction of buried penis. J Urol 1998;
2 Crawford BS. Buried penis. Br J Plast Surg 1977; 30: 96±9 160: 1482±4

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13 Alter GJ, Ehrlich RM. A new technique for the correction of the correction of an interesting condition that was ®rst
hidden penis in children and adults. J Urol 1999; 161: 455±9 reported in 1994 in the BJU. Whether this is truly
14 Shapiro SR. Surgical treatment of the `buried' penis. Urology congenital or not remains open to debate. The photo-
1987; 30: 554±9 graphs of the results of surgery look reasonable. In my
15 Chuang JH. Penoplasty for the buried penis. J Pediatr Surg
practice we tend to make a dorsal slit as the initial
1995; 30: 1256±7
surgical procedure, as is mentioned by the authors,
16 Redman JF. A technique for the correction of penoscrotal
fusion. J Urol 1985; 133: 432±3 leaving any further penile surgery if required until the
age of 3 or 4 years. We will be reporting our experience
fairly soon, as some children have required no further
Authors surgery other than the initial dorsal slit, although they
N. Smeulders, MA, FRCS, Clinical Research Fellow. are a minority. However, the surgery that Summerton et
D.T. Wilcox, MD, FRCS(Paed), Consultant Paediatric Urologist. al. describe is quite extensive, and if anything less can be
P.M. Cuckow, FRCS(Paed), Consultant Paediatric Urologist. performed it would be an obvious advantage.
Correspondence: Mr P.M. Cuckow, Great Ormond Street The paper by Smeulders et al. describes the GOSH
Hospital for Children, Great Ormond Street, London WC1N
approach to the problem. The surgery appears simple, the
3JH, UK.
illustrations are excellent and the end result, although
the traction suture does seem to be pulling on the penis,
appears good. That three papers have been published
about variations of the same pathology merely con®rms
Editorial comment
that this is not an easy condition to treat and surgery is
These three papers describe methods of treating varia- best left to experienced paediatric urologists. As no single
tions on the theme of the buried penis. The paper by operation has received widespread acclaim for the
Shenoy et al. discusses the use of liposuction together treatment of these conditions the `perfect answer' is
with surgical realignment of the skin in older children still awaited. Why do our adult urological colleagues not
(aged 9±13 years). Whilst the ®gures show a reasonable see this condition in the older patient? Have all the
cosmetic result, I cannot help wondering whether the patients with these conditions undergone surgical
same effect could not have been achieved by calorie correction in childhood? I doubt it. Does it usually
restriction, exercise and the use of either testosterone correct itself as the patient goes through puberty? I think
injections or dihydrotestosterone cream to enlarge the this is more likely, but I shall be interested to hear what
phallus. I am sure that the authors will react to my our colleagues in adult urology think.
comments in the correspondence section.
The paper by Summerton et al. discusses the surgical J.D. Frank, Assistant Editor

# 2000 BJU International 86, 523±526